The GOP health bill is doomed to toxic unpopularity, no matter how it's changed

The Republican health bill is very unpopular. But many people have been overthinking why it is unpopular, and have therefore missed why it cannot be amended to be made popular, as Republican leaders want to do.

On net, the bill cuts about $US1 trillion from government spending on healthcare over a decade. This means, to a first approximation, the bill would result in Americans spending an extra $US1 trillion of their own money on healthcare over the next decade.

Of course that’s unpopular.

You can think of the cuts as $US330 per year, per person. Or you can think of them as 7.3 million average Americans’ total healthcare costs over the next decade.

The cuts will be unevenly distributed — a majority of people won’t be directly affected, but those who lose the subsidies they currently use to buy health insurance will be out thousands of dollars — making the cuts all the more noticeable to those who get stuck picking up those bills the government won’t pick up anymore.

Republican senators’ efforts to tweak the bill are equivalent to rearranging the deck chairs on the Titanic. Yes, you can reallocate the pain. You can make things a little less expensive for young people and a little more expensive for old people; you can shift more of the federal insurance subsidy dollars to rural areas; you can make cuts to Medicaid slower to take effect yet deeper in the long run.

But there are just too many cuts to go around for people not to notice.

Not all health spending cuts have to be painful — but most do

You could reduce public spending on healthcare without making people angry if you made cheaper the healthcare people consume. This is hard, but last week, I laid out some ways to do this.

You could press drug prices down, for example, by letting the federal government use its buying power to negotiate down the prices it pays under Medicare. You could stop hospitals from merging, so they have less power to raise prices. You could widen the scope of services that people can get from nurse practitioners instead of doctors. You could issue more visas to foreign doctors willing to accept lower salaries.

These policies would cause some pain for doctors and hospital systems and pharmaceutical company shareholders. But they would make things easier for consumers of healthcare, which is most of us. And they would make it possible for the government to reduce spending on healthcare without forcing patients to spend more money of their own.

Of course, the Republican health bill doesn’t do any of this.

In fact, by pushing people out of Medicaid and into private insurance plans that don’t have as much leverage to negotiate low prices with doctors, it could cause the prices of healthcare services to go up.

Republicans like to claim that prices will fall because their law will “empower consumers,” which is their code word for the fact that their healthcare bill will saddle consumers with more of the responsibility to pay for their own healthcare. But there is little evidence that forcing consumers to pay more leads to savvier healthcare spending.

It doesn’t push prices down. It does cause people to consume less healthcare. Unfortunately, consumers do not appear to be very good at identifying and foregoing wasteful healthcare instead of useful healthcare — that is, people tend to forego treatments they actually need, but don’t have the money to pay for.

Let me tell you a story about healthcare spending accounts

One of the stupidest aspects of Republican healthcare rhetoric is the idea that consumers want to take charge of their own care by paying routine expenses from special, tax-advantaged accounts.

These accounts have been gradually foisted on Americans over the decades. Your employer most likely asks you if you want a Health Savings Account or a Flexible Spending Account. I’ve resisted using one because they are such a pain, but I broke down and set up an FSA this year through Business Insider because I decided it was stupid to forego the tax savings.

So I put $US2,600 in the account and ADP sent me a debit card. I started using it at the doctor’s office, at the pharmacy, at the physical therapist. (I threw out my back this spring, which is a reason I’ve been a little crankier than usual.)

Then, after a few months, I got a letter in the mail from ADP saying they needed my receipts. Receipts? I thought ADP got those straight from the providers. It seems they do get them from CVS, but not from the medical providers. I was supposed to be uploading those receipts through a website. Instead, I threw them away.

If I had to upload the receipts, then what was the point of the debit card? If the system requires that much paperwork, I might as well be submitting claim forms and getting checks in the mail.

Anyway, now I have to call those providers’ offices and get duplicate receipts and upload them and allow seven to 10 days for processing. Until I do that, I have been cut off from access to the money in the account — my own money — that only got in the account because Congress chose to offer a tax preference that I could only get by using such an account.

Who wants to deal with this crap?

Nobody wants to deal with this crap, that’s who

Officially, the Republican healthcare vision involves even more of this — tracking your healthcare funds in a special account, paying at the point of delivery for care you receive, and shopping around for your surgery like it’s a dream vacation.

But for the last seven years, Republicans haven’t been saying the problem with Obamacare was too little out-of-pocket spending. They have been saying the opposite.

They have been complaining that Obamacare plans have deductibles that are too high. That coinsurance payments are too high. That insurance under Obamacare isn’t good insurance because people have to pay so much after they have already paid premiums.

This was an effective political argument because this is, in fact, one of the things people hate about Obamacare. It’s what my friends who have been on Obamacare exchange plans complain about. People don’t like spending out of pocket. They don’t want more consumer direction. They want less.

The problem is, fixing that problem would have cost money. So Republicans lied. They said they’d give people insurance with lower deductibles. But then they wrote a law that would result in eye-wateringly high deductibles — for example, a deductible around $US6,000 for somebody with a family income of $US16,000.

Of course that’s unpopular. (News flash: Someone with an income of $US16,000 doesn’t have $US6,000 to pay toward a deductible.) But it’s what you have to do if you want the bill to cut a trillion dollars in government spending on healthcare without actually doing anything to make healthcare cheaper.

But then, this bill was never about improving healthcare or making healthcare consumers happy. It was about repealing the tax increases that Obamacare imposed. Both the House and the Senate bills would indeed do that.

And as long as that’s the core goal, there’s no way to restructure the law to make people not hate it.